Antidepressants

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
amitriptyline HCl AMITRIPTYLINE HCL TABLET Y Age Restriction BILL FFS  
amitriptyline HCl ELAVIL TABLET Y Age Restriction BILL FFS  
bupropion HCl BUPROPION XL TAB ER 24H Y   BILL FFS  
bupropion HCl WELLBUTRIN SR TAB SR 12H Y   BILL FFS  
bupropion HCl BUPROPION HCL SR TAB SR 12H Y   BILL FFS  
bupropion HCl BUPROPION HCL TABLET Y   BILL FFS  
buspirone HCl BUSPIRONE HCL TABLET Y   BILL FFS  
citalopram hydrobromide CITALOPRAM HBR SOLUTION Y   BILL FFS  
citalopram hydrobromide CITALOPRAM HBR TABLET Y   BILL FFS  
citalopram hydrobromide CELEXA TABLET Y   BILL FFS  
desipramine HCl DESIPRAMINE HCL TABLET Y Age Restriction BILL FFS  
desvenlafaxine succinate DESVENLAFAXINE SUCCINATE ER TAB ER 24H Y   BILL FFS  
desvenlafaxine succinate PRISTIQ TAB ER 24H Y   BILL FFS  
doxepin HCl DOXEPIN HCL CAPSULE Y Age Restriction BILL FFS  
doxepin HCl DOXEPIN HCL ORAL CONC Y Age Restriction BILL FFS  
duloxetine HCl CYMBALTA CAPSULE DR Y   BILL FFS  
duloxetine HCl DULOXETINE HCL CAPSULE DR Y   BILL FFS  
escitalopram oxalate ESCITALOPRAM OXALATE TABLET Y   BILL FFS  
escitalopram oxalate LEXAPRO TABLET Y   BILL FFS  
fluoxetine HCl PROZAC CAPSULE Y   BILL FFS  
fluoxetine HCl FLUOXETINE HCL CAPSULE Y   BILL FFS  
fluoxetine HCl FLUOXETINE HCL SOLUTION Y   BILL FFS  
fluoxetine HCl FLUOXETINE HCL TABLET Y   BILL FFS  
fluvoxamine maleate FLUVOXAMINE MALEATE TABLET Y   BILL FFS  
imipramine HCl IMIPRAMINE HCL TABLET Y Age Restriction BILL FFS  
lithium carbonate LITHIUM CARBONATE CAPSULE Y   BILL FFS Oct 01, 2020
lithium carbonate LITHIUM CARBONATE TABLET Y   BILL FFS Oct 01, 2020
lithium carbonate LITHOBID TABLET ER Y   BILL FFS Oct 01, 2020
lithium carbonate LITHIUM CARBONATE ER TABLET ER Y   BILL FFS Oct 01, 2020
mirtazapine REMERON TAB RAPDIS Y   BILL FFS  
mirtazapine MIRTAZAPINE TAB RAPDIS Y   BILL FFS  
mirtazapine REMERON TABLET Y   BILL FFS  
mirtazapine MIRTAZAPINE TABLET Y   BILL FFS  
nefazodone HCl NEFAZODONE HCL TABLET Y   BILL FFS  
nortriptyline HCl NORTRIPTYLINE HCL CAPSULE Y Age Restriction BILL FFS  
nortriptyline HCl PAMELOR CAPSULE Y Age Restriction BILL FFS  
nortriptyline HCl NORTRIPTYLINE HCL SOLUTION Y Age Restriction BILL FFS  
paroxetine HCl PAROXETINE HCL TABLET Y   BILL FFS  
paroxetine HCl PAXIL TABLET Y   BILL FFS  
sertraline HCl SERTRALINE HCL ORAL CONC Y   BILL FFS  
sertraline HCl ZOLOFT ORAL CONC Y   BILL FFS  
sertraline HCl ZOLOFT TABLET Y   BILL FFS  
sertraline HCl SERTRALINE HCL TABLET Y   BILL FFS  
venlafaxine HCl VENLAFAXINE HCL ER CAP ER 24H Y   BILL FFS  
venlafaxine HCl EFFEXOR XR CAP ER 24H Y   BILL FFS  
venlafaxine HCl VENLAFAXINE HCL ER TAB ER 24 Y   BILL FFS  
venlafaxine HCl VENLAFAXINE HCL TABLET Y   BILL FFS  
amoxapine AMOXAPINE TABLET V Age Restriction BILL FFS  
bupropion HCl FORFIVO XL TAB ER 24H V   BILL FFS  
bupropion HCl BUPROPION XL TAB ER 24H V   BILL FFS  
buspirone HCl BUCAPSOL CAPSULE V   BILL FFS  
citalopram hydrobromide CITALOPRAM HBR CAPSULE V   BILL FFS  
citalopram hydrobromide CITALOPRAM HBR SOLUTION V   BILL FFS  
clomipramine HCl CLOMIPRAMINE HCL CAPSULE V Age Restriction BILL FFS  
clomipramine HCl ANAFRANIL CAPSULE V Age Restriction BILL FFS  
desvenlafaxine DESVENLAFAXINE ER TAB ER 24H V   BILL FFS  
dextromethorphan HBr/bupropion AUVELITY TAB IR ER V   BILL FFS  
duloxetine HCl DRIZALMA SPRINKLE CAP DR SPR V   BILL FFS  
escitalopram oxalate ESCITALOPRAM OXALATE CAPSULE V   BILL FFS  
escitalopram oxalate ESCITALOPRAM OXALATE SOLUTION V   BILL FFS  
esketamine HCl SPRAVATO SPRAY V Pharmacy PA BILL FFS  
fluoxetine HCl FLUOXETINE DR CAPSULE DR V   BILL FFS  
fluvoxamine maleate FLUVOXAMINE MALEATE ER CAP ER 24H V   BILL FFS  
gepirone HCl EXXUA TAB ER 24H V   BILL FFS  
gepirone HCl EXXUA TAB24HDSPK V   BILL FFS  
imipramine pamoate IMIPRAMINE PAMOATE CAPSULE V Age Restriction BILL FFS  
isocarboxazid MARPLAN TABLET V   BILL FFS  
levomilnacipran HCl FETZIMA CAP SA 24H V   BILL FFS  
levomilnacipran HCl FETZIMA CAP24HDSPK V   BILL FFS  
lithium citrate LITHIUM CITRATE SOLUTION V   BILL FFS  
olanzapine/fluoxetine HCl OLANZAPINE-FLUOXETINE HCL CAPSULE V   BILL FFS  
paroxetine HCl PAROXETINE HCL ORAL SUSP V   BILL FFS  
paroxetine HCl PAROXETINE CR TAB ER 24H V   BILL FFS  
paroxetine HCl PAROXETINE ER TAB ER 24H V   BILL FFS  
paroxetine HCl PAXIL CR TAB ER 24H V   BILL FFS  
phenelzine sulfate PHENELZINE SULFATE TABLET V   BILL FFS  
phenelzine sulfate NARDIL TABLET V   BILL FFS  
protriptyline HCl PROTRIPTYLINE HCL TABLET V Age Restriction BILL FFS  
selegiline EMSAM PATCH TD24 V   BILL FFS  
sertraline HCl SERTRALINE HCL CAPSULE V   BILL FFS  
tranylcypromine sulfate TRANYLCYPROMINE SULFATE TABLET V   BILL FFS  
trazodone HCl RALDESY SOLUTION V   BILL FFS  
trazodone HCl TRAZODONE HCL TABLET V   BILL FFS  
trimipramine maleate TRIMIPRAMINE MALEATE CAPSULE V Age Restriction BILL FFS  
venlafaxine besylate VENLAFAXINE BESYLATE ER TAB ER 24 V   BILL FFS  
vilazodone HCl VILAZODONE HCL TABLET V   BILL FFS  
vilazodone HCl VIIBRYD TABLET V   BILL FFS  
vortioxetine hydrobromide TRINTELLIX TABLET V   BILL FFS  
zuranolone ZURZUVAE CAPSULE V Pharmacy PA BILL FFS  
mirtazapine MIRTAZAPINE TABLET   BILL FFS  
olanzapine/fluoxetine HCl OLANZAPINE-FLUOXETINE HCL CAPSULE   BILL FFS  
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